Canales Ortho

Is the patient a minor?

Yes, the patient is a minor
No, the patient is not a minor

Patient Information - Child

Name*

Preferred Name

Gender*

Male
Female

Date of Birth*

Age

Please enter a number from 1 to 150.

Grade*

School Attends*

Home Phone

Cell Phone*

Street Address*

City*

State*

ZIP Code*

Name/Relationship of person accompanying patient to today's appointment*

Who Has The Legal Custody Of The Patient?*

Names please.

Names Of Siblings and Birthdates

Name	Birthdate

Have We Treated Any Family Members?*

Yes
No

If We Have, Who?*

Whom may we thank for referring

Valpak
Dentist
Google
Website
Friend
Family
Other

Patient Information - Adult

Name*

Preferred Name

Gender*

Male
Female

Date of Birth*

Home Phone

Cell Phone*

Street Address*

City*

State*

ZIP Code*

Email*

Employer*

Employment Occupation*

Employer Address*

Employer City*

Employer State*

Employer ZIP Code*

Work Phone

Number of Years Employed*

Have We Treated Any Family Members?*

Yes
No

If We Have, Who?*

Whom may we thank for referring

Valpak
Dentist
Google
Website
Friend
Family
Other

Martial Status

Marital Status of Responsible Party?*

Responsible Party (#1)

Same as Patient Information

Responsible Party's Name (1)*

Relationship To Patient*

Parent
Guardian
Step Father
Step Mother

Date of Birth*

Street Address*

City*

State*

ZIP Code*

How Long At This Address?*

Cell Phone*

Work Phone

Employer*

Years Employed*

Occupation*

Email*

Responsible Party (#2)

Responsible Party's Name (2)*

Relationship To Patient*

Parent
Guardian
Step Father
Step Mother

Date of Birth*

Street Address*

City*

State*

ZIP Code*

How Long At This Address?*

Cell Phone*

Work Phone

Employer*

Occupation*

Email*

Spouse / Partner Information

Same as Patient Information

Name (If Applicable)

Date of Birth

Employer

Occupation

Employer Address

City

State*

ZIP Code*

Years Employed

Work Phone

Cell Phone

Email

Primary Insurance Information

Dental Insurance?

Check here if no orthodontic coverage will be applied

Insurance Company*

Employer/Group Name*

Subscriber/Employee*

Subscriber's Date of Birth*

Insurance Phone Number*

Group Number*

Subscriber ID/SSN*

Relationship To Patient*

Secondary Insurance Information

Dental Insurance?

Check here if no orthodontic coverage will be applied

Insurance Company*

Employer/Group Name*

Subscriber/Employee*

Subscriber's Date of Birth*

Insurance Phone Number*

Group Number*

Subscriber ID/SSN*

Relationship To Patient*

Emergency Contact Information

Emergency Contact Name*

Relationship to Patient*

Home Phone

Cell Phone*

Medical History

Physician's Name*

Physician's Phone*

Date of Last Physical Exam

Is the patient under medical treatment now?*

Yes
No

Has the patient been hospitalized for any surgical operations or serious illness in the past five years?*

Yes
No

Please describe the surgical operation(s) or illness(es).*

Is the patient taking medication(s) including non-prescription medicine?*

Yes
No

If yes, what medications(s)?*

Does the patient use tobacco?*

Yes
No

Is the patient allergic to any medications or substance, including metals?*

Yes
No

If yes, what?*

Has Menstruation Begun?*

Yes
No

Females Only

If yes, what date?*

Females Only

Is the patient pregnant, or think they may be?*

Yes
No

Females Only

Has the patient reached puberty?*

Yes
No

Child Only

Has the patient ever been evaluated for airway obstruction and/or sleep APNEA?*

Yes
No

Ever taken bisphosphonates (EX: FOSAMAX) for osteoporosis?*

Yes
No

If yes, specify*

Please Check All That Apply:

If so, specify:

Please Read:

We are passionate about our mission to give everyone a great smile. Please help us help you and your child by letting us know of any delayed development, social disabilities, ADD or ADHD, Bipolar, Autism, etc.

Dental History

Dentist*

Date of last cleaning?

Is the patient anxious or nervous about dental treatment?*

Yes
No

Does the patient require premeditation for dental treatment?*

Yes
No

Does the patient feel pain to any of their teeth?*

Yes
No

Does the patient have sores or lumps in or near mouth?*

Yes
No

Has the patient had any head, neck or jaw injuries?*

Yes
No

If yes, Please describe:

Does the patient have any ongoing jaw problems with:

Chronic Clicking or Popping?
Pain?
Difficulty Opening or Closing?
Difficulty in Chewing?

Does the patient clench or grind their teeth?*

Yes
No

Does the patient bite their lips or cheeks frequently?*

Yes
No

Has the patient ever had speech therapy?*

Yes
No

If yes, Please Describe:

Is there any outstanding dental treatment to be completed?*

Yes
No

If Yes, Please Describe:

Has the patient ever had instruction on the correction method of brushing and flossing your teeth?

Yes
No

Does the patient have any of the following oral habits:

Nail Biting?
Thumb Sucking?
Tongue Thrust while swallowing?
Mouth Breathing?

How many times a day does the patient brush?

Please enter a number from 0 to 20.

Please check the boxes below which describe the problem(s) for which the patient is seeking treatment:

Crowding
Extra Space
Teeth Stick Out Too Far
TMJ Problems
Poor Bite Relationship
Missing Teeth
Extra Permanent Teeth
Teeth Erupting in the Wrong Position
Other

Other:

Has the patient had an orthodontic evaluation or treatment before?*

Yes
No

If so, when and by whom?

Authorization and Release

TO THE BEST OF MY KNOWLEDGE THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED AND IT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES TO THE PATIENT’S MEDICAL STATUS. I GIVE CANALES ORTHODONTICS PERMISSION TO PERFORM AN ORTHODONTIC EXAMINATION.